Print Inspection: RL005090

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (# 2) received service in a manner that protected dignity and supported a homelike environment. Findings include, but are not limited to: On 06/24/25 at 8:40 am, the resident’s bathroom sink was observed and was found to be non-functional. On 06/24/25 at 8:57 am, Staff 2 (RCC) reported the kitchen sink had been disabled due to a previous flooding incident caused by the resident. However, Staff 2 thought the bathroom sink should be working. On 06/24/25 at 9:05 am, the surveyor and Staff 2 checked the bathroom sink together and confirmed it was not operational. Multiple staff interviews indicated it had been between four to six months since the bathroom sink had not been functioning and was no longer in use. When asked how the resident’s personal hygiene needs, including brushing his/her teeth and washing his/her face, were being met, staff reported the resident was escorted to the public restroom in the morning and afternoon to complete personal hygiene tasks. The need to ensure the resident received care with dignity and in a manner that supported a homelike environment during personal hygiene was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Office Manager) on 06/25/25. The staff acknowledged the findings.

1. Water has been turned back on in the resident's sink in bathroom and kitchen area. 2. Water will remain on in resident's room. 3. Staff will check resident's room to make sure water is not left running and causing flooding. 4. Office Manager and Admin will be responsible for overseeing the water stays on and monitoring.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to report incidents of abuse to the local Seniors and People with Disabilities (SPD) office and/or failed to promptly investigate injuries of unknown cause and report to the local SPD office if abuse could not be ruled out for 2 of 2 residents (#s 1 and 3) whose incident reports were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the MCC in 03/2025 with diagnoses including dementia. Resident 3’s progress notes, dated 04/03/25 through 06/23/25, and incident reports, dated 04/06/25 through 04/26/25, were reviewed, and the following was identified: * Staff documented a bruise on the resident’s left chest area, approximately four by five cm in size, with unknown cause; and * There was no documented evidence the incident was reported to SPD and no immediate investigation completed to reasonably rule out abuse. The facility was asked to report the injury to the local SPD office on 06/24/25. Confirmation was received on 06/25/25 at 9:19 am. The need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Coordinator), and Staff 3 (Office Manager) on 06/25/25. The staff acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2025 with diagnoses including Alzheimer’s disease and traumatic brain injury. The resident’s 04/08/25 through 06/20/25 progress notes and incident investigations were reviewed, and staff were interviewed. The following was identified: * On 04/10/25 Resident 1 was involved in a resident-to-resident altercation, in which the other resident “slapped” Resident 1’s hands; and * There was no documented evidence the incident was reported to the local SPD office. In an interview on 06/24/25 at 1:10 pm, with Staff 1 (Administrator) and Staff 5 (Resident Care Nurse/LPN), Staff 5 reported she was unaware the altercation should have been reported. The surveyor requested the facility report the incident to the local SPD office. Confirmation of the report was received on 06/24/25 at 2:00 pm. The need to report resident-to-resident altercations which involved physical contact was discussed with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 on 06/25/25 at 11:45 am. They acknowledged the findings.

1. Reported to APS while surveyors were at facility. Staff will be retrained at staff development meeting on reporting and investigations. 2. Staff are being retrained at staff development meeting on 07/17/25. Staff also assigned an online training on Mandatory Reporting: Reporting and Investigation Abuse and Neglect. 3. The investigations will be monitored daily. 4. The RCC, LPN, and Admin will be responsible for monitoring this daily.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff were provided with fire and life safety training every other month and to document all required fire drill elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 01/2025 through 06/2025 was reviewed on 06/24/25. The following was identified: 1. There was no documented evidence all staff were provided with fire and life safety training every other month. 2. Fire drill documentation did not include one or more of the following required elements: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Evacuation time needed. 3. Staff were not aware of the designed point of safety for residents in the event of an evacuation. 4. During a fire drill on 05/04/25, one resident was identified as refusing to participate in the drill. There was no documented evidence of how the facility addressed the issue. The need to provide fire and life safety training to all staff on opposite months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Coordinator), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. They acknowledged the findings.

1. Fire and life safety training every other month. All fields will be completed on the documentation and if there is a problem, it will be documented on the steps taken the addressed the issue. 2. Staff will be assigned a training. All staff will be retrained on evacuation so everyone is aware where the designated point of safety is. 3. We will review at every month's staff development meeting and make sure our fire drills are in compliance. 4. Maintenance, Office Manager, and Admin will oversee the completion and monitoring.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: Fire and life safety documentation from 01/2025 through 06/2025 was reviewed on 06/24/25. In an interview on 06/24/25 at 1:10 pm, Staff 1 (Administrator) was unable to provide documentation that residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the facility within 24 hours of admission or re-instructed annually. The need to provide fire and life safety instruction to residents within 24 hours of admission and to provide re-instruction at least annually was discussed with Staff 1 on 06/24/25 at 1:10 pm and with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. They acknowledged the findings.

1. All residents are being instructed again on evacuation methods, responsiblities, general safety procedures, and designated meeting places. This will be documented and signed. 2. This has been added to our checklist for admissions, as well as added to the calendar for annual retraining. 3. We will have all documentation signed and it will be evaluated every year for retraining. 4. Office Manager and Admin will be responsiblefor monitoring and completion of training and documentation.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair, grounds were kept orderly, and garbage was stored in covered refuse containers. Findings include, but are not limited to: The outside of the facility was toured on 06/23/25. The following deficiencies were identified: * Courtyard pathways had drop-offs up to 3” from the concrete to the planting beds, which caused a potential tripping hazard for residents; * Dead branches were in the planting bed on the street-side of the facility; and * The lid of a dumpster located in the parking lot was open. The need to maintain pathways in good repair, to keep the grounds orderly, and to keep garbage containers covered was discussed with Staff 1 (Administrator) on 06/24/25 at 1:10 pm and with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. The findings were acknowledged.

1. The dead branches have been removed. The dumpster lid has been closed since surveyor was at facility. Bark has been purchased and will be distributed to eliminate drop-offs. 2. New landscapers have been hired to keep this maintained. 3. This will be monitored weekly. 4. Maintenance, Office Manager, and Admin will oversee completion and monitoring.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair, and the facility was kept free of unpleasant odors. Findings include, but are not limited to: The interior of the facility was toured on 06/23/25 at 2:15 pm and 06/24/25 at 10:55 am. The following was identified: * The carpet was stained in multiple areas throughout the facility; * Multiple doors, door frames, baseboards, and walls were scratched, scraped, and/or gouged; * Numerous kick plates on resident unit doors had black and/or white scrapes; * Multiple windowsills had an accumulation of dust; and * There was a pervasive odor of urine in Room 120 throughout the survey, from 06/23/25 through 06/25/25. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 06/24/25 at 1:30 pm. The need to ensure all interior materials and surfaces were kept clean and in good repair, and to keep the facility free of unpleasant odors, was discussed with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. They acknowledged the findings.

1. Will replace/repair carpet stains. Doors, frames, baseboards, and gouges will be repaired. Kick plates will be cleaned and/or replaced. Windowsills are free of dust. Carpet in room with odor has been shampooed and cleaned. Items have been removed that resident urinated on. 2. Will be checking for stains, scratches, scrapes, gouges, dust, and odors. 3. Weekly checks will be made to ensure we are in compliance. 4. Maintenance and Office Manager will be responsible for overseeing this is being completed and monitored.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a setting that promoted individuals’ rights of privacy, dignity, and respect. Findings include, but are not limited to: Refer to C200.

See C200.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C231, C420, C422, C510, and C513.

Refer to C200, C231, C420, C422, C510, and C513.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s service plans were reviewed and showed some information about residents’ interests. However, the facility had not fully evaluated the residents’: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and/or * Activities that could be used as behavioral interventions, if necessary. There was no specific/individualized activity plan in place that detailed what activities would be offered, when and how often they would occur, how they would be implemented, or how staff would assist residents with individualized activities. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Coordinator) and Staff 3 (Office Manager) on 06/25/25. The staff acknowledged the findings.

1. All resident's service plans will be updated to reflect their activities of choice, any accmmodations, limitations, and personalized activity plans. 2. Our LEC will be retrained on individualized activity plan policy and procedure. 3. Service plans will be updated quarterly, or a change needs to be made. 4. LEC, RCC, and Office Manager will be responsible for completion and monitoring.